Provider Demographics
NPI:1992021414
Name:MILLER, JERRY WADE
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:WADE
Last Name:MILLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 84
Mailing Address - Street 2:
Mailing Address - City:FARMERSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75442-0084
Mailing Address - Country:US
Mailing Address - Phone:903-441-2225
Mailing Address - Fax:
Practice Address - Street 1:133 MCKINNEY ST STE 202
Practice Address - Street 2:
Practice Address - City:FARMERSVILLE
Practice Address - State:TX
Practice Address - Zip Code:75442-2221
Practice Address - Country:US
Practice Address - Phone:903-441-2225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-08
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator